Injections for patients with movement disorders

[oneforfighting]

What do you all do for patients with significant tardive dyskinesia or choreiform movements? Does PO or IV sedation help keep them still enough to do ESI/MBBs/RFA?

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[schmee90]

Thanks for posting this I have a CESI patient referred for a cervical radic, it seemed subtle in clinic, however in the procedure room it was pretty significant, and I pulled the plug on the procedure before even putting local in.

 

[Agast]

Propofol stops the twitching. PO sedation to calm them would probably not be enough.

 

[oneforfighting]

Propofol stops the twitching. PO sedation to calm them would probably not be enough.

Next question would be, would you do propofol for just an injection?

 

[Agast]

I’m the wrong person to ask that question since I’m ASC only, and an anesthesia team is readily available per patient request. But if a patient has a unique set of circumstances it’s not about what the procedure needs, it’s what the patient needs.

I don’t like sedation for MRIs but some people are so claustrophobic they can’t make it without being knocked out. That’s why the service is available.

 

[bedrock]

I would never do a CESI under propofol. I can understand the rationale for a patient like the OP described. However, this is a clear referral to the closest academic center. The amount of risk to me, extra work and time to me and my staff are not compensated in our current system, so off to the tertiary care center they go. This is not worth the $200 dollars that we might get paid.

I understand why some people get claustrophobic in regular MRI tube. I don't understand if they can't deal with an open MRI where they can fully extend all 4 limbs. Particularly if they have both Xanax and an open MRI.

If a patient says they have to be completely knocked out for an OPEN mri, even with xanax, then the next referral I make is to psych.

I don't refer out lots of patients, however, a doc getting the SOS and tax exempt status of an HOPD academic center can deal with cases like this as the system certainly doesn't pay me enough to do it in PP.

 

[MitchLevi]

I’ve done two propofol CESI for a guy with CP. I don’t see the big deal TBH. I acknowledge the risk.

 

[lobelsteve]

I’ve done two propofol CESI for a guy with CP. I don’t see the big deal TBH. I acknowledge the risk.

For CP ok, but for Psych bad enough to be on TD causing meds, I wonder the benefit.

 

[oneforfighting]

Appreciate the input everyone

 

[Baron Samedi]

For TD could just try some benadryl.

 

[oneforfighting]

For TD could just try some benadryl.

Interesting. I read that it would make symptoms worse. Reference?

 

[Baron Samedi]

Interesting. I read that it would make symptoms worse. Reference?

My apologies-- I was thinking of acute dystonia.

Dystonic Reactions - StatPearls - NCBI Bookshelf

 

[Ducttape]

I’ve done two propofol CESI for a guy with CP. I don’t see the big deal TBH. I acknowledge the risk.

the big deal is documented in the ASA closed claims case file.

I understand why some people get claustrophobic in regular MRI tube. I don't understand if they can't deal with an open MRI where they can fully extend all 4 limbs. Particularly if they have both Xanax and an open MRI.

If a patient says they have to be completely knocked out for an OPEN mri, even with xanax, then the next referral I make is to psych.

I don't refer out lots of patients, however, a doc getting the SOS and tax exempt status of an HOPD academic center can deal with cases like this as the system certainly doesn't pay me enough to do it in PP.

this is an image of a high quality open MRI scan.

True Open MRI | MRI of Reston

Our 1.2T high-field Open MRI maintains superior image quality while providing a more confortable experience.

www.mriofreston.com

i can see why some people get claustrophobic under this, having to lie there for 45 minutes. it is clearly better, but sedation or the new seated MRI will be a gamechanger (i hate that term nowadays...)

 

[Crybaby]

I just did a RFA on a man with severe Parkinson's I ended up doing IV sedation with Versed and fentanyl (4 and 50) It worked well, I had talked the case over with another pain guy who is anesthesia based - he really did not want to take over as well with anesthesia at our hospital, they weren't too interested.
He has DBS so it had to be turned off- at our last ov before RFA, he turned off the DBS so I could see how bad his tremors were....... he wasn't lying, pretty violent tremors. Having him prone and sedated worked better than I thought. Truthfully I thought he would need deeper sedation.
After seeing his tremors without his DBS on, that device is a true miracle.

 

[lobelsteve]

I just did a RFA on a man with severe Parkinson's I ended up doing IV sedation with Versed and fentanyl (4 and 50) It worked well, I had talked the case over with another pain guy who is anesthesia based - he really did not want to take over as well with anesthesia at our hospital, they weren't too interested.
He has DBS so it had to be turned off- at our last ov before RFA, he turned off the DBS so I could see how bad his tremors were....... he wasn't lying, pretty violent tremors. Having him prone and sedated worked better than I thought. Truthfully I thought he would need deeper sedation.
After seeing his tremors without his DBS on, that device is a true miracle.

Delivering appropriate care are you? Well done.

 

[callmeanesthesia]

I just did a RFA on a man with severe Parkinson's I ended up doing IV sedation with Versed and fentanyl (4 and 50) It worked well, I had talked the case over with another pain guy who is anesthesia based - he really did not want to take over as well with anesthesia at our hospital, they weren't too interested.
He has DBS so it had to be turned off- at our last ov before RFA, he turned off the DBS so I could see how bad his tremors were....... he wasn't lying, pretty violent tremors. Having him prone and sedated worked better than I thought. Truthfully I thought he would need deeper sedation.
After seeing his tremors without his DBS on, that device is a true miracle.

Thanks for sharing. Challenging situation. What region was the RFA? If lumbar there’s a good likelihood you wouldn’t have to turn off the DBS. If cervical or thoracic it could be done bipolar with very minimal risk to device. That’s what I do for patients with AICDs.

 

[Espn123]

I’m just a pain doc but caution using so much versed in elderly patients. Sure it made your procedure easier but cognitive decline and the effects of midazolam are a thing

 

[lobelsteve]

I’m just a pain doc but caution using so much versed in elderly patients. Sure it made your procedure easier but cognitive decline and the effects of midazolam are a thing

Are you saying a single dose can have long term consequences? Show it.

 

[callmeanesthesia]

Are you saying a single dose can have long term consequences? Show it.

Determinants of Post-Operative Cognitive Decline in Elderly People - PubMed

In this pilot study, we observed a post-operative short-term cognitive decline following a lower limb surgery. We also identified pre and perioperative independent factors linked to cognitive decline following surgery. In a next stage, a larger cohort should be used to confirm the impact of...

pubmed.ncbi.nlm.nih.gov

Quick example from PubMed. Link in anesthesia literature to BZDs specifically is less firm, but postop cognitive decline is real and can be lasting.

 

[lobelsteve]

Meh. Really, really different. Length of time, type of surgery, comorbidities. And a pilot study.

 

[Espn123]

I feel confident in my statement. Midazolam is not benign in the elderly

 

[Crybaby]

I’m just a pain doc but caution using so much versed in elderly patients. Sure it made your procedure easier but cognitive decline and the effects of midazolam are a thing

I do not typically use much sedation, >75% of my patient are no sedation and do fine- he would have done great with no sedation if not for Parkinson's. The tremors were pretty violent once the DBS was turned off. I was surprised, really shocked. There would have been no way to do without sedation, at least humanely.
In my neck of the woods, benzos are still one of the more commonly rx'd sleep aids, sooooooo

Thanks for sharing. Challenging situation. What region was the RFA? If lumbar there’s a good likelihood you wouldn’t have to turn off the DBS. If cervical or thoracic it could be done bipolar with very minimal risk to device. That’s what I do for patients with AICDs.

It was a lumbar RFA. The surgeon who placed it wanted the device off. I am not yet brave enough to argue on that subject